EUROPEAN UROLOGY 57 (2010) 586–591

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Platinum Priority – Voiding Dysfunction

Editorial by Roger Dmochowski on pp. 592–593 of this issue

A Comparison of the Frequencies of Medical Therapies for

Overactive Bladder in Men and Women: Analysis of
More Than 7.2 Million Aging Patients

Brian T. Helfand a, R. Mark Evans b, Kevin T. McVary a,*

a
Northwestern University, Feinberg School of Medicine, Department of Urology, Chicago, IL, USA
b
Healthcare Education Products and Standards, American Medical Association, Chicago, IL, USA

Article info Abstract

Article history: Background: The study of overactive bladder (OAB) symptoms has historically
Accepted December 10, 2009 focused on women. However, it is now evident that men, including those with
Published online ahead of benign prostatic hyperplasia, have OAB symptoms that respond to anticholinergic
print on December 17, 2009 therapy. The current OAB treatment frequencies by gender are unknown.
Objective: The aim of the study was to compare the treatment patterns among men
Keywords: and women diagnosed with OAB.
Urinary bladder Design, setting, and participants: Patients 45 yr in the IMS Health data set with
overactive more than one diagnosis code for OAB during a 12-mo period ending December 2007.
Anticholinergic therapy Intervention: Treated patients filled a prescription for either an anticholinergic or a
Men tricyclic antidepressant medication; untreated patients did not.
Women Measurements: Frequencies of OAB diagnoses and medical therapies by age and
gender were compared.
Results and limitations: Of the 7 244 501 patients 45yr with an OAB diagnosis,
24.4% of these were treated; 75.6% went untreated. Only 25.6% of those treated
were men. The diagnosis and treatment frequency increased in both men and
women as a function of age. However, in every age group, there was a significantly
( p < 0.001) decreased proportion of men treated compared with women.
Conclusions: Despite OAB prevalence, many patients receive no medical treatment.
Although the usefulness of OAB medications in men is becoming increasingly
recognized, men are significantly less likely to be treated with OAB medications
than women.
# 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Northwestern University Feinberg School of Medicine, Department of

Urology, 303 E. Chicago Ave., Tarry 16-703, Chicago, IL 60611, USA. Tel. +1 312 908 8145;
Fax: +1 312 908 7275.
E-mail address: k-mcvary@northwestern.edu (K.T. McVary).

1. Introduction grouped into storage, voiding, and postmicturition symp-

toms [1]. Overactive bladder (OAB) symptoms represent a
Lower urinary tract symptoms (LUTS) is an umbrella term subset of storage LUTS that specifically includes urgency with
used to describe a constellation of symptoms that have been or without urge incontinence, frequency, and nocturia [1].

0302-2838/$ – see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2009.12.025
 EUROPEAN UROLOGY 57 (2010) 586–591
In all patients, storage symptoms can be related to a
number of etiologies (eg, infection, neurologic conditions,
bladder carcinoma) [2]. The traditional association in men,
especially older men with benign prostatic hyperplasia
(BPH), is that these symptoms originate with the prostate,
the symptoms of prostatism. However, it is well recognized
that urinary symptoms poorly correlate with underlying
pathophysiology. Similar storage and voiding symptoms
can also be produced by other forms of obstruction in men
(eg, urethral stricture, impaired detrusor contractility) [2].
In contrast, female LUTS were historically referred to as OAB
and were thought to originate almost exclusively from the
bladder [3]. However, it is now recognized that many
women with these symptoms have bladder outlet obstruc-
tion (BOO) and/or detrusor underactivity of the bladder.
Therefore, based on historic associations, incorrect termi-
nologies, and overlapping clinical presentations, the true
prevalence of OAB in both genders has been unknown.
Several recent studies have documented a similar overall
prevalence of OAB symptoms (ranging from approximately
8–20%) that increases as a function of age in both men and
women [4–9]. Interestingly, the prevalence of associated
incontinence appears to be different between genders [7,8].
OAB without urge incontinence is more common in men,
whereas associated incontinence has a female predominance.
The frequency of associated female incontinence increases
with age but significantly increases after approximately
45 yr. In contrast, male-associated incontinence increases
with age but rises sharply after approximately 65 yr.
Regardless of gender or etiology, OAB symptoms signifi-
cantly compromise health-related quality of life (QoL) [7,10].
Despite the impact of OAB symptoms, underreporting
secondary to a patient’s embarrassment stands as an obstacle
to successful treatment [11]. Even when diagnosed, OAB is
often left untreated [11,12]. As previously mentioned, this
lack of treatment has been particularly prevalent in men for a
number of reasons, including relatively decreased rates of
associated incontinence in men [3]. Furthermore, there has
been concern for the use of anticholinergic therapies in men
with BPH because of a fear of aggravating urinary retention
[13]. In addition, alternative medical and surgical therapies
(eg, a-adrenergic antagonists, transurethral resection of
the prostate) have traditionally been used to treat BPH,
even when OAB symptoms were the primary complaint
[14,15].
Anticholinergic therapy has recently been shown to be
safe in men with OAB and BPH [16,17]. Although it is still
unclear which parameters (eg, optimal postvoid residual
volume) delineate an increased risk of urinary retention,
using anticholinergics in men with OAB significantly
improves symptoms [16,18].
Most of the research conducted on treatment frequen-
cies for LUTS/OAB symptoms has historically been con-
ducted on women. However, recent data suggest that the
prevalence of OAB symptoms is similar in both genders
[5,7]. Therefore, it was of interest to determine if their
treatment frequencies were similar. The aim of the present
analysis was to compare the frequency of medical therapies
for OAB in a large population of men and women.
587
2. Materials and methods
The IMS Health patient claims data set encompassed a 1-yr period
ending December 2007. This data set included integrated administrative
claims from >85 different national private health care plans in the
United States and contained information on 9 991 730 patients of all ages
with a current International Classification of Diseases, 9th revision (ICD-9),
diagnostic code for OAB (596.xx, 788.3x). We limited our data set to
patients 45 yr. Prescription drug data were linked directly to those
patients with an OAB diagnosis. Medication use was recorded for all OAB
medical therapies at the generic level as well as the drug-class level.
Medications for OAB included the antimuscarinic and tricyclic agents
(eg, tolterodine, oxybutinin, solifenacin, darifenacin, hyoscyamine,
dicyclomine, trospium, flavoxate, propantheline). We also documented
common male comorbidities (eg, BPH, ICD-9 codes 600.xx, 596.0,
788.2x; erectile dysfunction, codes 302.72, 607.84), female comorbid-
ities (postmenopausal vaginal atrophy, code 627.3; multiple sclerosis,
code 340.xx), and gender-neutral comorbidities (eg, diabetes, code
250.xx and hypertension, codes 401.x–404.xx). For the purposes of the
study, patients with a diagnosis of OAB who filled a prescription for an
OAB medication (defined as either an anticholinergic and/or tricylic
medication) during the study period were categorized as treated; those
who did not were classified as untreated.
Statistical analyses using SAS v.9.2 (SAS, Cary, NC, USA) were used to
compare the frequencies of medical therapies between different groups
of patients. Specifically, we performed tests comparing proportions, and
the standard normal Z table was used to assess for significance. In
addition, x2 analyses were used to test for trends.
3. Results
The IMS Health data set included clinical information on
187 195 026 patients. Men represented 47.2% (n = 88 448 968)
of this population. Within the database, we identified a
subset of patients (n = 9 991 730; 5.3% of total population)
with a diagnosis of OAB. Specific analysis demonstrated that
of the 102 556 189 patients 45 yr of age, 7 244 501 (7.1%)
had a diagnosis of OAB (Fig. 1). The overall prevalence of
OAB increased as a function of age: 4.9% of all patients were
45–54 yr, 6.7% of patients were 55–64 yr, and 9.6% of
patients were >65 yr. Fig. 2 shows that the OAB prevalence
also increased as a function of age in both genders ( p
trend < 0.001). Interestingly, there was a significantly
( p < 0.001) higher prevalence of OAB in every age group of
women compared with men. The OAB prevalence also
increased at different rates depending on gender and age
group. For example, an additional 2.6% of female patients
between 55 and 64 yr of age carried an OAB diagnosis
compared with women between 45 and 54 yr. A similar
overall increase was observed in the prevalence of OAB
women in the >65 yr age group. Men exhibited a similar
increase in the prevalence of OAB between the two
youngest age groups. Interestingly, the greatest increase in
prevalence (3.5%) occurred in men >65 yr compared with
men 55–64 yr.
Of the total population of patients 45yr, 24.4% (n = 1
767 077) were treated pharmacologically for their OAB
symptoms. More than 74% (n = 1 314 342) of this treated
group were women (Fig. 1). Specific analysis by gender
revealed that only 17.1% (n = 452 735) of men 45 yr with
OAB were provided medical therapies during the study
588 EUROPEAN UROLOGY 57 (2010) 586–591

Fig. 1 – The frequency of overactive bladder (OAB) medical therapy in >7.2 million patients with a diagnosis of OAB. Of the >187 million patients in the IMS
Health data set, 7 244 501 were I45 yr and had a diagnosis of OAB. The estimated prevalence of OAB was 5.6% and 8.4% among men and women,
respectively. Analysis of treatment rates in male patients revealed that 24.4% of patients were treated and 75.6% were untreated. A significantly higher
percentage of women received medications during the study period compared with men.

period, which was significantly ( p < 0.001) less than the
number of women treated (28.6%; n = 1 314 342; Fig. 1).
Subgroup analyses revealed that the proportion of
treated patients significantly increased as a function of
age for both men and women ( p trend < 0.001; Fig. 3).
However, the percentage of patients that received pharma-
cologic therapy increased at different rates based on gender.
For example, 22% of female patients between the ages of 45
and 54 yr were treated for OAB, in comparison with 28% and
33% of patients ages 55–64 yr and >65 yr, respectively
(Fig. 3). This represented an approximately 5–6% increase in
treatment rates based on age group. In comparison, an
additional 3% of men between the ages of 55 and 64 yr were
treated. Interestingly, the largest increase in treatment
frequency (7%) was observed in the male >65 yr age group.
This increased frequency was proportionately greater than
similar-age female counterparts.
Finally, in an attempt to better understand what drives
physicians to treat patients with OAB, we analyzed the
treatment prevalence in patients based on the presence of

Fig. 2 – The prevalence of overactive bladder (OAB) diagnosis in >102 million patients as a function of age and gender. Patients from the IMS data set I45 yr
of age were identified. The prevalence of a diagnosis of OAB was determined by both age group and gender. The overall prevalence of OAB in the data set
was 7.1%. The frequency of OAB diagnoses increased significantly ( p trend <0.001) as a function of increasing age in both genders. In every age group,
significantly more women were diagnosed than men ( p < 0.001).
 EUROPEAN UROLOGY 57 (2010) 586–591 589

Fig. 3 – The frequency of treated and untreated patients for overactive bladder (OAB) symptoms as a function of both age and gender. The frequency of
medical therapy use was determined in male and female patients included in this study. Subgroup analysis based on patient age demonstrated there was
an increase in the frequency of medical therapy by age group. However, a significant increased percentage of women were treated in comparison with
similar-age male counterparts. Interestingly, the largest increase in the rate of treatment occurred in men >65 yr (21%) compared with men between the
ages of 55 and 64 yr (14%).

comorbidities associated with OAB (eg, BPH, erectile
dysfunction, postmenopausal vaginal atrophy, multiple
sclerosis, hypertension, dyslipidemia, diabetes) [13,19–21].
Obesity as a comorbidity was not evaluated because of
the known unreliability of these codes rather than lack
of association or low prevalence in this population. In
general, the presence of any one of these comorbidities
was associated with an increased frequency of medical
treatment for OAB. For example, 18.6% and 19.0% of men
with BPH and erectile dysfunction were treated with
pharmacologic therapy, respectively. In contrast, a signifi-
cantly greater proportion of women with codiagnoses of
either postmenopausal vaginal atrophy (31.7%) or multiple
sclerosis (38.6%) were treated with OAB medications.
Patients with codiagnoses such as hypertension, dyslipide-
mia, and diabetes were associated with a 25.9%, 24.1%, and
26.5% frequency of treatment for OAB symptoms, respec-
tively. Taken together, although men with either BPH or
erectile dysfunction tend to be treated more frequently than
men without these comorbidities, the prevalence of treat-
ment is still relatively decreased compared with patients
with other comorbidities.
4. Discussion
Many studies have documented the prevalence of OAB
symptoms [5–8]. However, to our knowledge, no study has
reported the associated frequency of medical therapies. The
present study confirms that the diagnosis of OAB increases
linearly as a function of age in both genders. In addition, we
report that the frequency of medical therapy mirrors this
trend. However, although the percentage of patients in the
treated groups increases in both men and women, women
are significantly more likely to receive medical therapies in
any age group.
Approximately 7.1% of patients 45 yr within the IMS
Health data set have a diagnosis of OAB. Subgroup analysis
by gender demonstrated that the prevalence among aging
men and women is approximately 5.6% and 8.4%, respec-
tively. These rates are similar to prior reports of prevalence
estimates of OAB using a claims database [9]. However, our
results are lower than recent OAB prevalence estimates in
adults 40 yr ranging between approximately 11% and 16%
for men and approximately 13% and 17% for women [5–7].
The differences in prevalence estimates are likely based on
differences in estimating OAB prevalence. This study used
ICD-9 diagnostic codes to determine the prevalence of OAB,
whereas many prior studies used questionnaires to survey
patients. Thus a higher prevalence would be expected in
studies that actively investigate a diagnosis.
Numerous studies demonstrated that OAB has a pro-
foundly negative effect on both subjective and objective
measures of QoL [7,10]. In fact, it has been shown that OAB
symptoms can lead to depression and low self-esteem and
have an impact on many social situations [22]. However, the
present study shows that only a minority of all patients,
particularly men, with a diagnosis of OAB (approximately
24%) are provided medical therapy.
One potential reason for the relative low frequency of
treatment in both men and women may be the associated
cost. Several studies recently estimated the economic
burden of OAB disease (including direct medical costs,
direct nonmedical costs, and indirect costs) at more than
$12 billion annually [23]. Therefore many patients may
not elect to start medical therapies secondary to cost
alone. In addition, many patients may have opted for
lifestyle/behavioral alterations (eg, decreased fluid intake,
smoking cessation) before initiating pharmacologic ther-
apy. Other reasons for lower rates of treatment include
insufficient relief of symptoms and side effects of the
medication. Physician or patient preference for nondrug
approaches may also be a factor. However, although all
these factors may contribute to the lack of administered
medical therapies, they certainly do not explain the entire
phenomenon or gender differences.
Perhaps the observed discrepancies and gender bias in
treatment trends are related to the presence of incontinence
or other comorbidities. The National Overactive Bladder
590 EUROPEAN UROLOGY 57 (2010) 586–591
Evaluation Program provided data on the prevalence and
burden of OAB symptoms [7]. The results of the study
suggested that although the prevalence of OAB symptoms
was similar among men and women, the frequency of women
with OAB symptoms and incontinence increased at a faster
rate with age compared with men. Similar results can be
extrapolated from our study because there was a steady but
significant increase in treatment by age in women. Therefore,
if incontinence is the driving factor for medical intervention,
then it is not surprising we see a higher but steady proportion
of women being treated in each age group, including women
>65 yr. In addition, it is of note that women with
comorbidities that may predispose to incontinence (eg,
postmenopausal vaginal atrophy, multiple sclerosis) were
significantly more likely to be treated than men with any
other comorbidity. Interestingly, the presence of dyslipide-
mia, a seemingly unrelated disease, increased treatment
frequency. The following possible reasons account for this
finding: (1) Dyslipidemia directly increases OAB symptoms, a
prospect that should evoke further investigation; (2)
dyslipidemia may be associated with other comorbidities
that increase OAB symptoms; and (3) other biases unrelated
to dyslipidemia may be present. Although this association
does not imply causality, further investigation into the
mechanisms underlying this relationship is warranted.
Taken together, our data suggest that the presence of OAB
and associated incontinence may contribute to some of the
gender discrepancies of treatment.
The etiology of male OAB symptoms is thought to arise
from BPH-related BOO, leading to ischemia, cholinergic
denervation, and detrusor overactivity [24,25]. Thus, al-
though they are not codependent, men with BPH often have
OAB. Interestingly, the present results indicate that < 20% of
these patients are treated with OAB medications, despite
growing evidence that anticholinergic agents can safely and
effectively treat male OAB symptoms, even in patients with
urodynamically confirmed BOO [16,26,27]. Reasons for
withholding treatment in this population may be related
to a historic misclassification of these symptoms as prosta-
tism [28]. Therefore many of these men may have been
treated with other forms of medical therapy for BPH. In fact, a
recent study demonstrated that most men with OAB
symptoms and no BPH diagnosis were prescribed these
medications [14,15]. In addition, men in this study may not
have received treatment due to mild symptom severity, a lack
of associated incontinence or bother, side effects of the
medications, and intervention with other BPH therapies
(medication and surgery). Taken together, men may have
been proportionally undertreated in this study due to the
presence and concern of LUTS secondary to BPH. Further
education in the use of OAB medications in this group of
patients is needed.
Several limitations of this study deserve mention. First,
the IMS Health data set documents the diagnoses and
treatment patterns of a large insured population. Therefore
the treatment patterns in other populations (ie, uninsured
or Medicare enrollees) should be examined. In addition,
because this database contains limited information on
patients 75 yr of age, other studies specifically addressing
OAB treatment in this population should be performed.
Also, ICD-9 coding does not provide information about the
continuation and/or effectiveness of treatment. Because
OAB has a poorly understood natural history with
spontaneous annual remission rates of approximately
30% and rather high discontinuation rates for medical
therapies [29,30], it is currently unknown how many patients
continue to receive medical therapies and/or experience
OAB symptoms in this data set. In addition, OAB diagnoses
were determined by ICD-9 coding, and thus the types of
symptoms were not able to be obtained. Thus the definition
of OAB used and the severity of symptoms are subject to
debate. In addition, it would have also been useful to evaluate
the frequency of therapies in relation to the prevalence of
incontinence, data that were not readily available. Finally,
because OAB symptoms in men have historically been related
to BPH, other medical (eg, a-adrenergic antagonists) or
surgical therapies may have been prescribed. It would be
interesting to note the frequencies of these therapies in
comparison with OAB medications.
5. Conclusions
The current study demonstrates that the diagnosis and
treatment of OAB increases with age in both genders.
However, although physicians are becoming increasingly
aware of OAB symptoms in men, the frequency of treatment
is still significantly decreased in comparison with women.
Further education regarding the availability and efficacy of
pharmacologic therapy in both men and women is needed
for patients and physicians.
Author contributions: Kevin T. McVary had full access to all the data in the
study and takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study concept and design: Helfand, Evans, McVary.
Acquisition of data: Helfand, Evans.
Analysis and interpretation of data: Helfand, Evans, McVary.
Drafting of the manuscript: Helfand.
Critical revision of the manuscript for important intellectual content:
Helfand, Evans, McVary.
Statistical analysis: Helfand.
Obtaining funding: None.
Administrative, technical, or material support: Helfand, Evans.
Supervision: McVary.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including
specific financial interests and relationships and affiliations relevant to
the subject matter or materials discussed in the manuscript (eg,
employment/affiliation, grants or funding, consultancies, honoraria,
stock ownership or options, expert testimony, royalties, or patents filed,
received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
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